This disclosure relates generally to clinical documentation, and specifically to improvements in medical coding. In particular, the disclosure relates to ontologically driven medical coding systems and related methods, including compositional natural language processing (NLP) techniques for ICD type (International Classification of Diseases) coding standards, and other medical coding systems. Applications include computer assisted coding (CAC) for medical conditions and treatments, for example procedural coding systems for billing, diagnostic, statistical and analytic purposes.
The ICD coding system was developed in order to provide a standard tool for epidemiology and health care management, including clinical and hospital services. ICD classifications encompass a range of medical conditions including diseases and other disorders, as well as other, more nuanced factors including symptoms, complaints, abnormal findings, external causes of injury or disease, and social circumstances. Different ICD classification systems are also utilized to document patient treatment and reimbursement, including inpatient hospital care, emergency room care, and outpatient services including clinical and professional services.
The application of natural language processing tools to ICD classification systems provides substantial opportunities for increased efficiency and improved clinical documentation. In addition, ontologically driven NLP processing techniques can be utilized to smooth the transition to newer, more complete coding standards, including implementations of the ICD-10-CM (Clinical Modification) and ICD-10-PCS (Procedure Coding System) standards.